Comprehensive Care and Integration Specialist (CCIS) Team
Supporting clients with complex health needs through an integrated approach to care.
Quick facts
Service type: Health & Wellness
Eligibility: Adults 18+ with complex health conditions residing in mid-East/East Toronto. For additional considerations, please see below.
Delivery: In person, virtual, phone
Fee: Free
Partners: East Toronto Health Partners, Cota, St. Michael's Homes, Michael Garron Hospital
Program description
WoodGreen’sclinical social workers strive to fill gaps in care for clients living with complex health and psychosocial issues. Our Comprehensive Care and Integration Specialistsconnect clients to essentialservices and supports;coordinate follow-up care;and providecase management, counsellingand advocacy on housing, legal, financial and immigration issues.
We work with clients to develop individual Coordinated Care Plans and support their care providers to work as a team. Our goal is to bridge the gap between acute and medical care providersand the community sector.
Eligibility
Patients/clients with significant gaps in care
Patients/clients who may struggle to follow up on care recommendations
Patients/clients who have a history of multiple Emergency Department (ED) visits, are Alternate Level of Care (ALC) or at risk for ongoing visits and in-patient stays
Patients/clients who experience challenges related to the social determinants of health (e.g., housing, income)
Patients/clients who would benefit from integrating the work of multiple health providers
Please consider referring clients with complex health needs from the following groups:
Individuals experiencing mental health and/or addiction issues
Psychogeriatric populations (55+ with mental health and/or addiction issues)
Frail elderly
Frequently Asked Questions
Who can make a referral to the CCIS Team?
Anyone over the age of 18 can be referred to the CCIS Team for support. Clients can self-refer or be referred by a health care or support professional.
Does the client need to consent to participating in the CCIS Team program prior to submitting a referral?
Yes, the client needs to consent to participating in the program prior to submitting a referral form.
How do you define complex health issues?
The CCIS Team works with clients who have 4 or more chronic conditions and complex psycho-social needs. For example, clients living with mental health and/or addiction issues and physical health issues who need support with connecting to community resources so they can live safely at home, would be a good fit for this program.
What are some common scenarios on the CCIS Team?
Clients 18+ may be experiencing physical health issues that make it difficult for them to connect with their health care providers.
Clients may be experiencing addiction and mental health issues such as depression, anxiety as well as cognitive challenges such as dementia and need support with connecting to community resources to better cope with these issues.
Clients being referred to CCIST may also be experiencing food insecurity, precarious housing, bug infestations, hoarding, legal and immigration issues and need support with coordinating their care to address the presenting challenges.
Does the CCIS Team support clients with housing issues?
The Social Workers on the CCIS Team are not housing workers and we do not have access to housing units. However, staff can support clients with completing a housing application and/or connecting to housing supports in their community.
How will the CCIS Team help me?
After a referral is made to the CCIS Team the client is connected to a Comprehensive Care Integration Specialist (CCI Specialist) who will provide intensive case management support for 3 months to support clients with creating a Coordinated Care Plan and building community connections that will support their psychosocial, mental and physical health needs.
Services for Adults with Developmental Disabilities
Our programs connect adults with developmental disabilities to financial services, affordable housing, medical care, recreational activities and life skills training.
Services for Children with Developmental Disabilities
This program supports children with developmental disabilities, as well as their families, providing accessible and meaningful opportunities for community participation.
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In person, virtual, on the phone
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In-person, virtual, on the phone
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